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Targeted Call for Research - public call for research priorities in Aboriginal and Torres Strait Islander health

This submission reflects the views of
Organisation Name: 
Mothers and Babies Research Centre
Personal Details
Specific Questions
1. What is the research priority (a significant research knowledge gap or unmet need) you are nominating? How would a TCR in this area greatly advance our understanding of this issue? (200 word maximum): 
Focus upon a culturally acceptable, integrated, trauma informed approach to reducing premature birth and low birth weight in Aboriginal and Torres Strait Islander infants. Aboriginal and Torres Strait Islander women have double the rate of premature delivery and low birth weight infants compared to non-Indigenous Australian women. The burden of illness for these infants is life long and high. Focussing only on physical aspects of causation is understandable given our specialised medical systems, but is not likely to adequately maximise prevention. Engagement in antenatal care in the first trimester and addressing psychological challenges such as inter-generational trauma from the Stolen Generation and ongoing social disparities is vital. Maternal stress directly influences the hypothalamic-pituitary-axis (HPA) function of the offspring and induces life-long changes in stress responsiveness [1, 2]. Perturbation in stress responsiveness has been associated with increased vulnerability to mental health disorders including depression, schizophrenia and bipolar disorder [3]. PTSD is the one established mental health association with premature delivery [4]. 1. Weerth, C.d., J. Buitelaar, and M. EJK., Prenatal programming of behaviour, physiology, and cognition. Neurosci Biobehav, 2005. 29:p. 207-208. 2. Owen, D., M. Andrews, and S. Matthews, MAternal adversity, glucocorticoids and programming of neuroendocrine function and behaviour. Neurosci Biobehav, 2005. 29: p. 209-226. 3. Cottrell, E. and J.R. Seckl, Prenatal stress, glucocorticoids and the programming of adult disease. Front Behav Neurosci, 2009. 3: p. 19. 4. Shaw, J.G., et al., Posttraumatic stress disorder and risk of spontaneous preterm birth. Obstet Gynecol, 2014. 124(6): p. 1111-9.
2. What are the relevant Australian Government Priorities, and/or Ministerially-agreed State and Territory health research priorities linked to your nominated priority? (200 word maximum): 
The Fifth National Mental Health Plan 2016-19 highlights the need to “increase access to services for Indigenous Australians” [5] and a NSW strategic plan has been developed, ‘Healthy, Safe and Well: A strategic health plan for children, young people and families 2014–24’ [6]. It points out that: • Aboriginal babies are more likely to be of low weight (11% versus 5.9%) • Only 60% of mothers have first antenatal visit <14 weeks of pregnancy • Over 40% of women reported physical violence and 20% sexual violence after age 15 • Aboriginal women are 5 times more likely to smoke in pregnancy The plan notes that priorities in pregnancy are: • Antenatal care • Accessing information • Mental health • Safety It recommends strategies that: • Increase awareness of violence, abuse and neglect on health over time • Build capacity to appropriately respond to victims of violence, abuse and neglect These reports highlight the need for culturally inclusive, trauma informed approaches supporting and respecting the health needs of Indigenous women during their pregnancy to minimise the impact of psychological distress on women and their infants. 5. Department of Health. Fourth national mental health plan: an agenda for collaborative government action in mental health 2009-2014. 2009; Available from: http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-f-plan09-toc. 6. NSW Government. Healthy, Safe and Well: A strategic health plan for children, young people and families 2014–24. 2014; Available from: http://www.kidsfamilies.health.nsw.gov.au/publications/healthy,-safe-and-well-a-strategic-health-plan-for-children,-young-people-and-families-2014-24/.
3. How would a TCR in this area contribute to Aboriginal and Torres Strait Islander health and improve health outcomes for the individual and/or community? (200 word maximum): 
The objectives of this TCR are to reduce the incidence of both premature birth and low birth weight infant rates to equal the rates for non-Aboriginal infants. For this to occur multiple risk factors need to be addressed. Of utmost importance is the development of a culturally acceptable healthcare model which promotes engagement in antenatal care in the first trimester. The following then need to be addressed with urgency: depression, PTSD, exposure to stressful events and consumption of anything harmful to the fetus. To successfully achieve these goals, engagement of the highest level thinkers from various research backgrounds needs to occur in a collaborative manner. Researchers from the fields of Aboriginal and Torres Strait Islander health, obstetrics, endocrinology, psychiatry, and social sciences need to create a ‘think tank’. If the ‘gap’ could truly be closed the impact upon individual Aboriginal and Torres Strait Islander families as well as Australia as a whole would be immense.
4. How will the TCR reduce the burden of disease on the health system and Australian economy? (200 word maximum): 
There has been minimal cost analysis focus in Australian literature regarding the life-long costs of premature delivery and low birth weight infants. However American literature estimates the cost of prematurity per infant to be US$51,600 until early childhood in 2009. Another problem facing some Aboriginal and Torres Strait Islander communities is Fetal Alcohol Spectrum Disorders (FASD). In a remote sample of Aboriginal and Torres Strait Islander infants, 12% had FASD [7]. It is likely that this TCR would reduce FASD by early engagement in a culturally acceptable antenatal service. The lifetime cost for each individual with FASD has been estimated to exceed US$1.4 million in 2002. Thus the Australian health burden and the economy are likely to benefit greatly by the establishment of this TCR. 7. Fitzpatrick, J., et al., Prevalence of fetal alcohol syndrome in a population-based sample of children living in remote Australia: the Lililwan Project. Journal of Paediatrics and Child Health, 2015. 51(4): p. 450 - 457.
5. Are there any reports or findings that support your nomination for the suggested topic? (200 word maximum): 
• ‘Healthy, Safe and Well: A strategic health plan for children, young people and families 2014–24’ is a comprehensive health plan that covers many of the ideas in this proposal [6]. • A paper by our research group, submitted but not yet in press, reports upon the incidence of PTSD in pregnant Aboriginal and Torres Strait Islander women of rural and remote NSW communities. It was found that 40% self-report clinically significant symptoms as compared to 4% in non-Aboriginal women [8]. • Premature and low birth infants have increased risk for development of coronary heart disease, hypertension, stroke and type 2 diabetes mellitus in adult life [9] • Maternal stress in pregnancy is associated with poor stress responsiveness in the infant, alterations to maternal infant bonding and life-long risk of mental illness in the infant [1, 2]. • PTSD is the one established mental health association with premature delivery [4]. 8. Mah, B., et al., Post-traumatic Stress Disorder symptoms in pregnant Australian Indigenous women residing in rural and remote New South Wales: A cross-sectional descriptive study. Submitted, 2016. Under review. 9. Barker, D., et al., Fetal nutrition and cardiovascular disease in adult life. The Lancet, 2003. 341(8850): p. 938-941. 9.

Page reviewed: 30 August, 2018